Cross-sectional analysis of recommendations for the treatment of hip and knee osteoarthritis in clinical guidelines.

Abstract

OBJECTIVE

To compare guideline recommendations for hip and knee osteoarthritis (OA) and their level of evidence.

DATA SOURCES

Medline, Embase, the Cochrane library, and websites of professional societies were searched in June 2020 using key words such as knee or hip osteoarthritis, degenerative arthritis, guideline, and practice guideline.

STUDY SELECTION

General treatment guidelines for OA of the hip or knee published in English. After 461 abstracts were screened, 31 publications (17 guidelines from 10 professional societies) were included for analysis.

DATA EXTRACTION

Three reviewers assessed the quality of the guidelines according to the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. The rating of evidence and strength of recommendation was extracted and standardized into the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

DATA SYNTHESIS

Of the 17 guidelines included, 6 (35%) were of high quality, 10 (59%) of moderate quality, and one (6%) of low quality. Guidelines published after 2017 were of good quality. Although guidelines generally agreed on a non-surgical multimodal concept including patient education, exercise, and weight loss in obese, some recommendations remained vague and the level of evidence varied widely. In pharmacological treatment, oral non-steroidal anti-inflammatory drugs were the mainstay for pain management. Guidelines published after 2017 were more cautious in their recommendation for the use of paracetamol and strong opioids. Disagreement was observed for chondroitin sulfate, glucosamine, and intraarticular hyaluronic acid injections. Recommendations were conflicting for the use of insoles, braces, and transcutaneous electrical stimulation (TENS). The main indications for hip/knee arthroplasty were severe, persisting pain and loss of function despite non-surgical treatment. No guideline defined a minimum time of conservative treatment before surgery.

CONCLUSIONS

We found a wide variation in evidence and strength of recommendations for OA treatment. Recommendations on when to refer patients for surgery remained unclear.